Reply to "AIDS turns 20"

The LLEGÓ e-newsletter Al Tanto keeps our aliados, afiliados and other stake holders, about important information for HIV/AIDS intervention and prevention services. It also provides information about upcoming opportunities and

In an effort to serve the people we work with better, we would like to hear from you about any suggestions you may have to improve this e-newsletter or what you would like to see included in it!

Prevention Counseling and the Client with HIV
Ongoing prevention counseling is an essential component of the management of persons with HIV infection. Each client encounter provides an opportunity to reinforce HIV prevention messages, and should document and assess:
1. The client's knowledge and understanding of the means of HIV transmission;
2. The client's HIV transmission behaviors since the last encounter with the
health care provider or counselor.

This encounter should be followed by a discussion of the strategies to prevent transmission that may be useful to the individual client. Partner
notification is an important component of HIV detection and prevention and should be pursued by the provider or by referral services.

Although the basic elements of HIV prevention messages have been unchanged since the introduction of Highly Active Antiretroviral Therapy (HAART), important observations regarding the impact of HAART upon transmission, and
individual risk behaviors have been noted. For example, low viral load that results from successful HIV therapy substantially reduces the likelihood of HIV transmission. Viral load tests measure the amount of HIV in the blood, but HIV is also present in semen and vaginal fluids, and the proportion of HIV in these fluids and the blood is not necessarily equal. Therefore, a very low or undetectable viral load measurement in the blood does not give a complete or true picture of total viral load in the body. So while HAART does substantially reduce the likelihood of HIV transmission, it is by no means a form of safer sex in itself and HIV positive individuals must be educated to use barrier protection while having vaginal or anal sex.

Similarly, mother to child HIV transmission was observed to decline in proportion to the maternal viral load at the time of delivery. However there
are exceptions, and mother to child transmission has been reported even in women with very low or "undetectable" viral loads. Therefore HIV
risk-reduction counseling remains an essential component of working with HIV positive women who may have unprotected sex because they wish to become pregnant and for those who are already receiving pre-natal care. For women of childbearing potential, the desire for pregnancy should be assessed at each encounter; women wishing to pursue pregnancy should be referred for
preconception counseling to reduce the risks of perinatal transmission and transmission to uninfected sexual partners. In women of childbearing age who wish to avoid pregnancy, condoms should be encouraged in addition to other
forms of contraception for prevention of HIV and STD transmissio!

Behavioral changes in HIV-infected individuals that impact prevention are an ironic consequence of successful treatment during this HAART era. An
association between knowledge of the benefits of HAART and relapse to high-risk activity is an undeniable fact of life among many HIV positive
individuals. For example, reports from urban gay communities in the U.S. clearly indicate rising rates of unsafe sexual practices with consequent
rising HIV seroprevalence rates. This trend has reached crisis proportions among gay youth and especially among minority gay youth. Powerful prevention messages that educate and re-educate while bringing supportive services and resources are essential if we are to avoid an uncontrollable epidemic both medically and financially. For example, to quote from a recent article (9/19/02) published in the Seattle Post-Intelligencer, ...

Drugs...cost as much as $12,000-$15,000 a year. The state's AIDS Prescription! Drug already in finanial trouble. In addition, poor adherence to HIV medication has been shown to be a predictor of poor adherence to HIV prevention strategies. More intensive adherence and
prevention counseling may be appropriate for Individuals who demonstrate repeated deficiencies in either area. Therefore, despite the strong
association between a reduced risk of HIV transmission and sustained low viral load, the message of HIV prevention should remain simple: Once infected, an HIV positive individual may transmit the virus at any time, and there is no
substitute for latex or polyurethane male or female condoms, other safer sexual behaviors (e.g., fewer partners, monogamy or abstinence), and cessation of any sharing of drug paraphernalia. Prevention counseling for clients
known to have HIV infection, including easy access to condoms and other means of prevention, remains a critical component of HIV primary care.

Counselors may wish to directly address the risks of using viral load outcomes with their patients as a factor in considering high-risk behavior.
HIV-infected persons who use injection drugs should receive counseling on risks associated with sharing needles and paraphernalia and encouraged to enroll in drug rehabilitation programs. It must also be noted that the most
effective and successful prevention messages are those tailored to the individual. These messages are culturally appropriate, practical, and relevant to the person's knowledge, background, beliefs and behaviors. The message, the manner of delivery, and the cultural context may vary greatly depending upon the client.

 Epidemiological Profile

HIV Prevalence Among Latino YMSM

A study conducted from 1994 to 1998 on 3,942 15-22 year old YMSM in 7 different cities found the following :

-The overall HIV prevalence rate for YMSM in this survey was 7.2% -Black, Latino, and Mixed-Race men were more likely to test HIV positive
..3.3% of white men tested positive, while 6.9% of Latino YMSM had contracted HIV.. the subgroup men of mixed race," who tested positive at a rate of 12.6%, is likely to include many Latinos.

Related Risk Factors
-The prevalence of unprotected anal sex (receptive and insertive) was 41%
-Latinos were more likely to get regularly or semi-regularly tested for HIV than every other group except Whites
-Gay-identified Latino MSM living in poverty and subjected to racism and homophobia are more likely to engage in high-risk sexual behavior and have higher rates of HIV

Interestingly, this study found that those YMSM who get tested for HIV regularly are more likely to contract HIV; those who test more frequently also tend to more regularly engage in unprotected sex. These findings seem to be primarily indicative of several possibilities: First, it seems to indicate that people who get tested more often feel that they need to get tested more
often, that they are more likely to engage in risky behavior than those who get tested infrequently or not at all. Second, it seems to point to the ineffectiveness of post-test counseling, in getting people not to engage in
highly risky behavior.

Lastly, despite that youth account for half of all new HIV cases in the United States, less than a quarter of all HIV prevention programs are designed or funded to address the needs of those youth who need it most, namely youth of color, homeless and runaway youth, recent immigrants, and YMSM.

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